CHI Saint Joseph Health Partners’ providers are dedicated to transforming patient care by working directly with patients to set health goals, participate in preventive strategies – like health screens – and navigate our sometimes confusing and complex health care system more skillfully. Our sophisticated technology supports our efforts by allowing us to reach out to a certain population of patients at once for a screening reminder, for example, or to identify individual patients in need of our direct assistance. Our system allows us to target our efforts, so our compassionate staff can make a real difference in the health of those we serve.
We have had many patient successes over the last few years, but one in particular stands out. It stands out because so many patients deal with hurdles like these, and never get the help they need. Thankfully, now with CHI Saint Joseph Health Partners model of care coordination and management, patients like this receive the care they deserve.
A diabetic for many years, Homer Bowlin was accustomed to daily blood glucose checks, medication and regular visits to his primary care provider. However, during a check up, his primary care provider found his A1c to be high and recommended that Mr. Bowlin start daily insulin injections. That’s when Teresa Crowell, BSN, RN, a health coach with CHI Saint Joseph Health Partners, stepped in to help.
Teresa met with Mr. Bolin, listened to his concerns and demonstrated how to give an injection. After assuring him that she would be a resource, she met Mr. Bowlin at his pharmacy, and along with the pharmacist, helped him get the needed medications and supplies. And to help him get started with this new routine, Teresa made a home visit the next day to demonstrate the proper technique for injections and needle disposal, and even provided him with a picture of the various injection sites he could use.
Encouraging Mr. Bolin and helping him comfortable with this new routine was important for his health and trust of Teresa as his coach. Since that experience, Teresa has been able to provide even more support to Mr. Bolin. Together they met with a dietitian who created menus to help vary his diet and even provided pictures of appropriate foods and portions. When his blood sugar seemed high, he called Teresa for help.
Mr. Bowlin’s team – his primary care provider, his RN Health Coach, dietitian and his pharmacist – are all an integral part of his long term good health. Together, they have been able to live out our organizational values and purpose to bring wellness, healing and hope to all!
A Path of Wellness
Frank Maraman is a very active 83 year-old man happy to begin working with a health coach to stay on a path of wellness and receive assistance with orthopedic issues. He worked part-time as a brick layer and has always been an active member of his community. Frank’s designated health coach, Dana Simpson, RN, began working closely with Dr. Renu Mahta, his primary care physician, to provide the very best care for him.
Dr. Mehta saw Frank and ordered a lumbar spine MRI, while Dana met Frank and his family for the MRI appointment. During this meeting, Frank’s family expressed their concern, leading Dana to request that Dr. Mehta order the MRI reading STAT. While the results indicated nothing acute, Dana remained in close contact with Frank until next steps were determined.
Later that evening, Frank’s daughter-in-law called Dana to express that Frank’s condition worsened. Dana directed her to take Frank to Sts. Mary & Elizabeth’s Hospital’s emergency room immediately. Frank was admitted to the hospital, where the staff discovered he had a tumor compressing and encasing his thoracic spine. Frank was immediately transferred to Jewish Hospital for surgery that evening to remove the tumor.
Frank is now in the outpatient locomotion program five days a week at Frazier Rehab and continues to grow stronger each day. Without Dana’s careful monitoring of and intervention for Frank, his health and well-being may have been jeopardized, and his outcome and experience may not have been as positive. Our RN health coaches are able to connect with patients most in need to ensure the very best care and best experience at the lowest possible cost.
Making a Difference
Ronald Redmon, 62, began seeing Dr. Donna Betz several years ago. He has a close relationship with her and does his best to take care of himself. Ronald struggles with back and neck pain caused by his Parkinson’s and car accidents. This pain prohibits him from doing daily tasks, such as driving, and requires physical therapy for improvement. For a while, Ronald qualified for physical therapy home visits but unfortunately, these visits expired. Without transportation, Ronald was unable to continue in the therapy he needed to regain his mobility and independence.
At this point, Megan Berger, one of our outpatient care coordinators, was put in touch with Ronald via his RN health coach, Shannon Troutman. Shannon had noted through reviewing our secured patient information that Ronald was no longer attending physical therapy sessions and wondered if he needed some assistance to get back on track. Dr. Betz was concerned too and hoped to refer him soon for the treatment he needed.
Megan spoke to Ronald regarding his physical therapy and they discussed how important it was for him to get some mobility back and live a better life. Megan was able to find a local resource that could provide Ronald with free transportation to his physical therapy appointments for whatever period of time he needed to go. Megan immediately called Dr. Betz to let her know that Ronald now had transportation. That day, Dr. Betz made the referral to physical therapy and within a week, Ronald was back on track.
Megan let Ronald know that he no longer had to worry about transportation for his medical appointments. He was thrilled to be
able to make his appointments on his own without having to rely on others. Ronald was also very excited to start physical therapy again so that he could get some pain relief and increased mobility in his back and neck. Ronald thanked Megan for her hard work.